Scope of Practice

The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.”Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license”.

What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time.

Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart.

This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.

While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.

Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.

The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.

Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.

“Half of primary care physicians in survey would leave medicine … if they had an alternative.” — CNN, November 2008

“Doctors are increasingly leaving the Medicare program given its unpredictable funding.” – Forbes, January 2013

Doctors, it seems, love medicine so much … that they’re always threatening to quit.

In some cases, it’s all in how the question is asked. (Because of methodology, several eye-catching surveys have since been discredited.)

But physicians’ mounting frustration is a very real problem, one that gets to the heart of how health care is delivered and paid for. Is the Affordable Care Act helping or hurting? The evidence is mixed.

Doctors’ Thoughts on Medicare: Not as Dire as Originally Reported

The Wall Street Journal last month portrayed physician unhappiness with Medicare as a burning issue, with a cover story that detailed why many more doctors are opting out of the program.

And yes, the number of doctors saying no to Medicare has proportionately risen quite a bit — from 3,700 doctors in 2009 to 9,539 in 2012. (And in some cases, Obamacare has been a convenient scapegoat.)

But that’s only part of the story.

What the Journal didn’t report is that, per CMS, the number of physicians who agreed to accept Medicare patients continues to grow year-over-year, from 705,568 in 2012 to 735,041 in 2013.

Lately, my virtual inbox in our electronic medical record has seen a surge in requests for prescriptions for the vaccine against Herpes Zoster, shingles. This has made me think a lot about our responsibility as physicians to inform patients about the evidence behind our recommendations – but who informs the patients when doctors are kept out of the loop or put under pressure to prescribe without seeing the patient?

What has happened is that our local Rite-Aid Pharmacy started to give these shots, covered by many insurers, but still requiring a doctor’s prescription.

I cannot give the shots in my clinic, because as a Federally Qualified Health Center, we are reimbursed at a fixed rate. The shingles vaccine costs more for us to buy than we charge for an entire office visit. I used to have the discussion about the shot, and would give patients a prescription to take to the pharmacy if they wanted it.

The pharmacy can give the shot at a profit, because it is considered a medication, just like a bottle of Lipitor.

The new system creates a bit of a dilemma for me. I get a message through the pharmacy that the patient wants the shot, and I don’t have the opportunity to sit down and review the effectiveness, side effects and long-term efficacy according to the available evidence with the patient.

For example, the shingles vaccine only cuts the risk of getting shingles in half. This is about the same effectiveness as the flu vaccine, but far less than, say, the vaccine against smallpox, which has now been eradicated.

Most patients are very surprised to hear about the 50% efficacy when I catch up with them at some later date; so many health care interventions are portrayed as both completely effective and absolutely necessary.

I see my role as a primary care physician as a guide and resource for patients, who are bombarded with overly optimistic claims and recommendations by mass media, drug companies and retailers.

In my last post on California and Texas’s imminent expansion of their scope of practice regulations, I didn’t cover one important question: what do patients actually want?

Fortunately, a study just released in Health Affairs looked into it, and the results are clear: many patients want to be seen by nurse practitioners (NPs) and physician’s assistants (PAs) – especially if it allows them to be seen sooner.

To be clear: generally, Americans still prefer being seen by a physician. But preferring a NP/PA – or “not having a preference” between a NP/PA and a physician – is a big deal; it insinuates that, for certain ailments, the public views a NP/PA as just as effective a clinician. That has significant repercussions for how care is delivered, particularly for young people and underserved populations.

Walgreens, the country’s largest drugstore chain, announced on April 4th that its 330+ Take Care Clinics will be the first retail store clinics to both diagnose and manage chronic conditions like asthma, diabetes, high blood pressure, and high cholesterol. The Nurse Practitioners (NPs) and Physician Assistants (PAs) who staff these clinics will provide an entry point into treatment for some of these conditions, setting Walgreens apart from competitors like Target and CVS whose staff help manage already-established chronic illnesses or are limited to testing for and treating minor, short-lived ailments like strep throat.

A one-stop shop for toothpaste, prescription drugs, and a diabetes diagnosis? The retail clinic phenomenon has its appeal: it allows patients convenience and better access to care through longer hours and more locations than our health care system now provides. Walgreens leaders bill their latest offering as a complementary service to traditional medical care. They envision close collaboration with physicians and even inclusion in Accountable Care Organizations, according to reporting by Forbes’ Bruce Japsen (though it’s not clear how the retailer would share the financial risk or savings in such a model).

Recently, I was having a discussion with a colleague about being a doctor. She confided in me that if someone asked her about becoming a doctor, she would tell him or her to become a nurse practitioner. After reading the emotional open letter to our policymakers in Washington DC, it may sound like a reasonable suggestion. After all, why go into this much debt and spend so much time in training if your prospects are not much better? More recently, the New York Times article points out job prospects for radiology trainees are thinning, meaning the well known “ROAD” (Radiology, Ophthalmology, Anesthesiology, and Dermatology) to success may soon become a road to nowhere if there are no jobs.

There in lies the question, why become a doctor? If the answer is to make money or to have an easy life, then you probably need to look for a new profession. With healthcare payment reform, doctors can expect lower salaries as bundled payment and cost cutting measures are instituted. Moreover, the demand for healthcare will go up as more patients have insurance, leading to higher patient volumes and the expectation to see more patients with the same amount of time.

Several folks have been kind enough to point out this story, and suggest that I may have an opinion on it:

[A woman from] Shrewsbury, Mass., claims that Dr. Helen Carter, a primary care physician at the UMass Memorial Medical Center in Worchester, refused to treat her because she is clinically obese…

It seems the good doctor has decided not to care for anyone (it is unclear if the prohibition applied to all patients or just to females) weighing over 200 lbs. Apparently there was a nearby specialty facility capable of caring for obese patients, so no one was being sent away with no resource to medical care.

There is nothing either illegal or unethical about this policy, according to the AMA and others. Much hullabaloo has ensued in the various comment trails, with many people stating that it should be (illegal. unethical, or both.) They are wrong. The only thing this physician has done is set her weight limit unreasonably low.

Here are the magic words: Scope of Practice. It means that doctors have not only the right but the ethical and legal responsibility to limit the care they provide based on their capabilities, their training and their experience, which together also translate to “comfort level”.

We frequently accept crossposts from smaller blogs and major U.S. and International publications. You'll need syndication rights. Email a link to your submission.

WHAT WE'RE LOOKING FOR

Op-eds. Crossposts. Columns. Great ideas for improving the health care system. Pitches for healthcare-focused startups and business.Write ups of original research. Reviews of new healthcare products and startups. Data-driven analysis of health care trends. Policy proposals. E-mail us a copy of your piece in the body of your email or as a Google Doc. No phone calls please!

THCB PRESS

Healthcare focused e-books and videos for distribution via THCB and other channels like Amazon and Smashwords. Want to get involved? Send us a note telling us what you have in mind.
Proposals should be no more than one page in length.

HEALTH SYSTEM $#@!!!
If you've healthcare professional or consumer and have had a recent experience with the U.S. health care system, either for good or bad, that you want the world to know about, tell us about it. Have a good health care story you think we should know about? Send story ideas and tips to editor@thehealthcareblog.com.